4.7  Breastfeeding difficulties

In your work helping mothers to breastfeed optimally, you may come across mothers who have one or more breastfeeding difficulties. It is very important that you know the common difficulties, how these can be prevented, and ways that you can help mothers to manage and overcome any problems. Table 4.1 summarises the common breastfeeding difficulties that mothers encounter, some prevention methods and possible solutions if problems develop.

Table 4.1  Breastfeeding difficulties and their solutions. (Source: adapted from Academic Education for Development (USAID) Linkages project)

Difficulty or conditionPreventionSolution

Engorgement

Correct positioning and attachment

Breastfeed immediately after birth

Breastfeed on demand (as often and as long as baby wants) day and night: 8–12 times per 24 hours

Allow baby to finish the first breast before switching to the second breast

Apply a cold compress (a cloth dipped in cold water) to breasts to reduce swelling; apply warm compresses to get milk flowing

Breastfeed more frequently or for longer

Improve infant positioning and attachment

Massage breasts

Express some milk

Apply a warm bottle

Sore or cracked nipples

Correct positioning of baby

Do not use bottles, dummies or pacifiers

Do not use soap on nipples

Make sure the baby is positioned well at the breast

Make sure the baby latches on to the breast correctly

Apply drops of breastmilk to nipples and allow to air dry

Remove the baby from the breast by breaking suction first

Begin to breastfeed on the side that hurts less

Do not stop breastfeeding

Do not wait until the breast is full to breastfeed; if full, express some milk first

Plugged breast ducts and mastitis (red, painful and swollen breast)

Get support from the family to perform non-infant care activities

Ensure correct attachment

Breastfeed on demand

Avoid holding the breast in scissors hold (with two fingers in the form of scissors)

Avoid sleeping on stomach (mother)

Avoid tight clothing

Use a variety of positions to rotate pressure points on breasts

Apply heat before the start of breastfeeding

Massage the breasts before breastfeeding

Increase maternal fluid intake

Rest (mother)

Breastfeed more frequently

Seek medical treatment; if mastitis, antibiotics may be necessary

If mother is HIV-positive: express milk and heat, treat or discard

Position baby properly

Insufficient breastmilk (mother ‘thinking’ she does not have enough milk)

Breastfeed more frequently

Exclusively breastfeed day and night

Breastfeed on demand at least every three hours

Correct positioning of baby

Encourage support from the family to perform non-infant care chores

Avoid bottles and pacifiers

Withdraw any supplement, water, formulas, tea or liquids

Feed the baby on demand, day and night

Increase frequency of feeds

Wake the baby up if it sleeps throughout the night or longer than three hours during the day

Make sure the baby latches on to the breast correctly

Reassure the mother that she is able to produce sufficient milk

Baby takes fore and hind milk

Insufficient breastmilk

Insufficient weight gain

Fewer than six wet diapers per day

Dissatisfied (frustrated and crying) baby

Same as above

Same as above

Refer the mother and baby to nearest health centre

Pause reading for a while and think of the difficulties of breastfeeding commonly encountered in your community and think about how you would try to prevent and solve these problems if they occur.

  • What will you advise a mother who thinks she does not have enough milk?

  • You should reassure the mother that breastmilk can be sufficiently produced as long as the baby sucks very well. To ensure sufficient milk production you can advise the mother to do the following:

    • Withdraw any supplement, water, formulas, tea or liquids she has been giving the baby
    • Feed the baby on demand, day and night
    • Increase the frequency of feeds
    • Wake the baby up if the baby sleeps a long time between feeds.

It is possible that you may encounter times where breastfeeding may be difficult because of situations that affect either the capacity of the baby to suck, the availability of the mother or the capacity of the mother to breastfeed. Table 4.2 summarises the solutions to a range of different situations where a mother is having problems breastfeeding.

Table 4.2  Special situations during breastfeeding and their solutions. (Source: adapted from Academic Education for Development (USAID) Linkages project)

Special SituationSolutions

Sick baby

Baby under six months: if the baby has diarrhoea or fever the mother should breastfeed exclusively and frequently to avoid dehydration or malnutrition

Breastmilk contains water, sugar and salts in adequate quantities, which will help the baby recover quickly from diarrhoea

If the baby has severe diarrhoea and shows any signs of dehydration, the mother should continue to breastfeed and provide ORS either with a spoon or cup

Baby older than six months: if the baby has diarrhoea or fever, the mother should breastfeed frequently to avoid dehydration or malnutrition. She should also offer the baby bland food (even if the baby is not hungry) and increase the frequency of feeding

If the baby has severe diarrhoea and shows any signs of dehydration, the mother should continue to breastfeed and add ORS

Sick mother

When the mother is suffering from headaches, backaches, colds, diarrhoea or any other common illness, she should continue to breastfeed her baby

The mother needs to rest and drink a large amount of fluids to help her recover

If the mother does not get better, she should consult a doctor and say that she is breastfeeding

Premature baby (baby born before nine months)

The mother needs support for correct breastfeeding

Breastfeeding is advantageous for pre-term infants; supportive holds may be required

Direct breastfeeding may not be possible for several weeks, but expressed breastmilk may be stored for use by the infant

If the baby sleeps for long periods of time, he/she should be unwrapped to encourage waking and held vertically to awaken

The mother should watch the baby’s sleep and wake cycle and feed during quiet-alert states

Crying is the last sign of hunger. Cues of hunger include rooting, licking movements, flexing arms, clenching fists, tensing body and kicking legs

Malnourished mothers

Mothers need to eat extra food (‘feed the mothers, nurse the baby’)

Mothers need to take micronutrients

Mother who is separated daily from her infant

The mother should express or pump milk and store it for use while separated from the baby; the baby should be fed this milk at times when he/she would normally feed

The mother should frequently feed her baby when she is at home

The mother who is able to keep her infant with her at the work site should feed her infant frequently

Twins

The mother can exclusively breastfeed both babies

The more each baby nurses, the more milk is produced

Inverted nipples

Detect during pregnancy

Try to pull nipple out and rotate (like turning the knob on a radio)

Make a hole in the nipple area of a bra. When a pregnant woman wears this bra, the nipple protrudes through the opening

If acceptable, ask someone to suckle the nipple

Baby who refuses the breast

Position the baby properly

Treat engorgement (if present)

Avoid giving the baby teats, bottles, pacifiers

Wait for the baby to be wide awake and hungry (but not crying) before offering the breast

Gently tease the baby’s bottom lip with the nipple until he/she opens his/her mouth wide

Do not limit duration of feeds

Do not insist on more than a few minutes if baby refuses to suckle

Avoid pressure to potential sensitive spots (pain due to forceps, vacuum extractor, clavicle fracture)

Express breastmilk, and give to the baby by cup

Mother who will be away from her infant for an extended period expresses her breastmilk; caregiver feeds expressed breastmilk from a cup.

The mother expresses breastmilk by following these steps:

  • Washes hands
  • Prepares a clean container
  • Gently massages breasts in a circular motion
  • Positions her thumb on the upper edge of the areola and the first two fingers on the underside of the breast behind the areola
  • Pushes straight into the chest wall
  • For large breasts, first lifts and then pushes into the chest wall
  • Presses the areola behind the nipple between the finger and thumb
  • Presses from the sides to express milk from the other segments of the breast
  • Repeats rhythmically: position, push, press; position, push, press
  • Rotates the thumb and finger positions

The mother stores breastmilk in a clean, covered container. Milk can be stored 8-10 hours at room temperature in a cool place and 72 hours in the refrigerator

The mother or caregiver gives the infant expressed breastmilk from a cup. Bottles are unsafe to use because they are difficult to wash and can be easily contaminated

HIV-positive mother who chooses to breastfeed

The mother should practice exclusive breastfeeding for six months. At six months the mother should introduce appropriate complementary foods

A mother who experiences breast difficulties such as mastitis, cracked nipples or breast abscess should breastfeed with the unaffected breast and express and discard milk from the affected breast

The mother should seek immediate care for a baby with thrush or oral lesions

A mother who presents with AIDS-related conditions (prolonged fever, severe cough or diarrhoea, or pneumonia) should visit a health centre immediately

A lactating mother should use condoms to protect herself from exposure to infected semen

HIV-positive mother who chooses to replacement feed

The mother should practice safe and appropriate use of infant formula or animal’s milk (with additional sugar) exclusively for the first six months

The mother should use a cup, not a bottle

The mother should NOT mix-feed – give only breastmilk substitutes, do not breastfeed

  • What solutions would you advise the mother of a sick baby under six months with diarrhoea?

  • You would advise the mother to breastfeed exclusively and frequently to avoid dehydration or malnutrition. You would explain to her that breastmilk contains water, sugar and salts in adequate quantities, which will help her baby recover quickly from diarrhoea. If the baby has severe diarrhoea and shows any signs of dehydration, tell the mother she should continue to breastfeed and provide Oral Rehyderation Solution (ORS) either with a spoon or cup.

4.6  Benefits of breastfeeding for the community

4.8  Key messages for optimal complementary feeding practices